Verification of RN/LPN License from US State of Original ...

Non-NURSYS? License

Verification of Original Licensure by Examination

Please complete the top portion of this form and forward to your licensing authority (board) if it does not participate with NURSYS?. (Please contact that board for fee and processing time.)

Select a License: Registered Nurse (RN) Licensed Practical Nurse (LPN)

Social Security Number:

Previous last name used:

Name (First, Middle, Last):

Address:

City:

State:

ZIP Code:

Original State Licensed:

License Number:

Name as it appears on original license:

I hereby authorize the release of my license data to the Washington State Nursing Commission.

Signature ___________________________________________________ Date _______________________

This portion to be completed by original licensing authority (Board) and mailed to Washington.

This is to certify ____________________________was issued license number _____________________ by

examination on _______________ to practice as RN LPN/VN

Examination: NCLEX State Board Test Pool Exam Date Passed ____________________ RN LPN

Current License Status: Active Not active

Expiration Date:

Has this license ever had disciplinary action? Yes No (if yes, attach explanation)

Disciplinary action pending? Yes No (if yes, attach explanation)

Currently under investigation? Yes No (if yes, attach explanation)

Name of Nursing School Completed: State/Province of School: Type of Nursing Program: Certificate

Diploma

Graduation date: ADN/ASN BSN MSN

(SEAL)

Return to:

Nursing Commission P.O. Box 47864 Olympia, WA 98504-7864

Signature

DOH 669-218 July 2019

State

Date

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